1
|
Chen JF, Yu SF, Chiu WC, Ko CH, Hsu CY, Lai HM, Chen YC, Su YJ, Kang HY, Cheng TT. Development and Comparison of Treatment Decision Tools for Glucocorticoid-Induced Osteoporosis. Diagnostics (Basel) 2024; 14:452. [PMID: 38396490 PMCID: PMC10887529 DOI: 10.3390/diagnostics14040452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Long-term Glucocorticoid (GC) use results in compromised bone strength and fractures, and several treatment recommendations have been developed to prevent fractures, but none have been validated in a real-world setting. This study aims to create a treatment decision tool and compares this tool to the treatment suggestions from the American College of Rheumatology (ACR), International Osteoporosis Foundation and European Calcified Tissue Society (IOF-ECTS), and GC-adjusted Fracture Risk Assessment Tool (GC-FRAX), above the intervention threshold. We utilized registry data gathered at Chang Gung Memorial Hospital at Kaohsiung, Taiwan, between September 2014 and April 2021. This research is a single-center, observational, and case-controlled study. We recruited participants using prednisone for at least 2.5 mg/day or the equivalent dose for over 3 months, excluding those younger than 40, those with malignancies, or those currently undergoing anti-osteoporosis therapy. The primary endpoint was new fragility fractures within 3 years, including morphometric vertebral fractures detected at baseline and with a follow-up thoracic-lumbar spine X-ray. Participants were randomly allocated into derivation and validation sets. We developed the Steroid-Associated Fracture Evaluation (SAFE) tool in the derivation cohort by assessing the weights of exploratory variables via logistic regression. Prediction performance was compared in the validation set by the receiver operating characteristic (ROC) curve, the area under the curve (AUC), and sensitivity and specificity. A total of 424 treatment-naïve subjects were enrolled, and 83 (19.6%) experienced new fractures within 3 years. The final formula of the SAFE tool includes osteoporosis (1 point), an accumulated GC dose ≥ 750 mg within 6 months (or equivalent prednisolone of ≥4.5 mg/day for 6 months) (1 point), a BMI ≥ 23.5 (1 point), previous fractures (1 point), and elderliness of ≥70 years (2 points). In the validation set, a treatment decision based on the SAFE ≥ 2 points demonstrated an AUC of 0.65, with a sensitivity/specificity/accuracy of 75.9/54.0/58.9, with an ACR of 0.56 (100.0/11.0/31.0), IOF-ECTS 0.61 (75.9/46.0/52.7), and GC-FRAX 0.62 (82.8/42.0/51.2). Among current GIOP recommendations, the SAFE score serves as an appropriate treatment decision tool with increased accuracy and specificity.
Collapse
Affiliation(s)
- Jia-Feng Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Wen-Chan Chiu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Chi-Hua Ko
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Chung-Yuan Hsu
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Han-Ming Lai
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Ying-Chou Chen
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Yu-Jih Su
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| | - Hong-Yo Kang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
- Center for Menopause and Reproductive Medicine Research, Department of Obstetrics and Gynecology, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan
- Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung 833, Taiwan; (J.-F.C.)
| |
Collapse
|
2
|
Morikawa T, Sakuma M, Nakamura T, Sonoyama T, Matsumoto C, Takeuchi J, Ohta Y, Kosaka S, Morimoto T. Effectiveness of a computerized clinical decision support system for prevention of glucocorticoid-induced osteoporosis. Sci Rep 2022; 12:14967. [PMID: 36056121 PMCID: PMC9440130 DOI: 10.1038/s41598-022-19079-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 08/24/2022] [Indexed: 11/09/2022] Open
Abstract
Glucocorticoids are widely used for a variety of diseases, but the prevention of glucocorticoid-induced osteoporosis is sometimes neglected. Therefore, the effectiveness of a computerized clinical decision support system (CDSS) to improve the performance rate of preventive care for glucocorticoid-induced osteoporosis was evaluated. We conducted a prospective cohort study of outpatients who used glucocorticoids for three months or longer and who met the indication for preventive care based on a guideline. The CDSS recommended bisphosphonate (BP) prescription and bone mineral density (BMD) testing based on the risk of osteoporosis. The observation period was one year (phase 1: October 2017-September 2018) before implementation and the following one year (phase 2: October 2018-September 2019) after implementation of the CDSS. Potential alerts were collected without displaying them during phase 1, and the alerts were displayed during phase 2. We measured BP prescriptions and BMD testing for long-term prescription of glucocorticoids. A total of 938 patients (phase 1, 457 patients; phase 2, 481 patients) were included, and the baseline characteristics were similar between the phases. The median age was 71 years, and men accounted for 51%. The primary disease for prescription of glucocorticoids was rheumatic disease (28%), followed by hematologic diseases (18%). The prevalence of patients who needed an alert for BP prescription (67% vs. 63%, P = 0.24) and the acceptance rate of BP prescription (16% vs. 19%, P = 0.33) were similar between the phases. The number of patients who had orders for BMD testing was significantly increased (4% vs. 24%, P < 0.001) after CDSS implementation. The number of patients who needed an alert for BMD testing was significantly decreased from 93% in phase 1 to 87% in phase 2 (P = 0.004). In conclusion, the CDSS significantly increased BMD testing in patients with a higher risk of glucocorticoid-induced osteoporosis, but did not increase BP prescription.
Collapse
Affiliation(s)
- Toru Morikawa
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
- Department of General Medicine, Nara City Hospital, Nara, Japan
| | - Mio Sakuma
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
| | - Tsukasa Nakamura
- Department of Infectious Diseases, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Tomohiro Sonoyama
- Department of Pharmacy, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Chisa Matsumoto
- Center for Health Surveillance and Preventive Medicine, Tokyo Medical University, Tokyo, Japan
| | - Jiro Takeuchi
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yoshinori Ohta
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
| | | | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan.
| |
Collapse
|
3
|
Iki M, Fujimori K, Nakatoh S, Tamaki J, Ishii S, Okimoto N, Kamiya K, Ogawa S. Guideline adherence by physicians for management of glucocorticoid-induced osteoporosis in Japan: a nationwide health insurance claims database study. Osteoporos Int 2022; 33:1097-1108. [PMID: 35022812 DOI: 10.1007/s00198-021-06265-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/06/2021] [Indexed: 12/12/2022]
Abstract
UNLABELLED Risk of fracture due to glucocorticoid-induced osteoporosis (GIO) can be reduced by anti-osteoporosis (OP) medications. The proportion of patients on long-term glucocorticoid therapy who received anti-OP medications according to the GIO management guidelines has increased in recent years, but is still suboptimal. INTRODUCTION Adherence of physicians to guidelines for glucocorticoid (GC)-induced osteoporosis (GIO) management is currently unclear. This study aimed to clarify the state of guideline adherence by physicians in Japan and identify factors associated with guideline adherence using a nationwide health insurance claims database (NDBJ). METHODS Patients aged ≥ 50 years who were prescribed GC for ≥ 90 days after 180 days without a GC prescription and who were followed up for osteoporosis (OP) management for the subsequent 360 days during the period spanning 2012-2018 were selected from the NDBJ. Guideline adherence was evaluated with the proportion of patients who received OP management as recommended by the Japanese guidelines. Information on previous vertebral and hip fractures, dementia, and polypharmacy was obtained. Factors associated with OP management were evaluated by logistic regression analysis. RESULTS A total of 512,296 patients were considered to be at high risk of fracture according to the guidelines. Proportions of patients receiving OP management (BMD testing or anti-OP medications) have increased in recent years. In 2017, 33.7% of men and 55.3% of women received OP management in the initial 90 days of GC therapy. Female sex, previous anti-OP medications, polypharmacy, and higher GC dose were significantly associated with receiving OP management, while dementia showed an inverse association. A prior history of hip fracture, a strong risk factor for future fracture, was not significantly associated with receiving OP management. CONCLUSIONS Although guideline adherence by physicians has increased in recent years, it remains suboptimal. Further efforts to improve guideline adherence are necessary. TRIAL REGISTRATION NUMBER The present study is not registered.
Collapse
Affiliation(s)
- M Iki
- Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka, 589-8511, Osaka-Sayama, Japan.
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka, 589-8511, Osaka-Sayama, Japan.
| | - K Fujimori
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka, 589-8511, Osaka-Sayama, Japan
- Department of Health Administration and Policy, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - S Nakatoh
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka, 589-8511, Osaka-Sayama, Japan
- Department of Orthopedic Surgery, Asahi General Hospital, 477 Tomari, Asaimachi, Shimo-Nikawa-gun, Toyama, 939-0798, Japan
| | - J Tamaki
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka, 589-8511, Osaka-Sayama, Japan
- Department of Hygiene and Public Health, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - S Ishii
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka, 589-8511, Osaka-Sayama, Japan
- Department of Regulatory Science, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachiouji, Tokyo, 193-0392, Japan
| | - N Okimoto
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka, 589-8511, Osaka-Sayama, Japan
- Okimoto Clinic, 185-4 Kubi, Yutaka-machi, Kure, Hiroshima, 734-0304, Japan
| | - K Kamiya
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka, 589-8511, Osaka-Sayama, Japan
- Department of Hygiene and Public Health, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan
| | - S Ogawa
- National Database Japan-Osteoporosis Management (NDBJ-OS) Study Group, Department of Public Health, Kindai University Faculty of Medicine, 377-2 Oono-higashi, Osaka, 589-8511, Osaka-Sayama, Japan
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8511, Japan
| |
Collapse
|
4
|
Song BW, Kim AR, Kim MA, Kim HS, Lee SG. Status of Glucocorticoid-Induced Osteoporosis Preventive Care in Korea: A Retrospective Cohort Study on the Korean National Health Insurance Service Database. Medicina (B Aires) 2022; 58:medicina58020324. [PMID: 35208647 PMCID: PMC8879589 DOI: 10.3390/medicina58020324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/11/2022] [Accepted: 02/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: It is crucial to prevent osteoporosis in patients receiving long-term glucocorticoid (GC) treatment. This study aimed to investigate the frequency and associated factors of preventive care for glucocorticoid-induced osteoporosis (GIOP) in Korea. Materials and Methods: Using the Korean National Health Insurance Service database, we identified 37,133 individuals aged ≥ 20 years who commenced long-term (≥90 days) oral GC between 2011 and 2012. High-quality GIOP preventive care was defined as either a bone mineral density (BMD) test, calcium and/or vitamin D supplementation, or prescription osteoporosis medications within 6 months of GC initiation. Multivariable logistic regression models were used to calculate odds ratios (ORs) for associated factors for high-quality GIOP preventive care. Results: The mean age was 49.8 years, and 18,476 (49.8%) patients were female. The frequency of high-quality GIOP preventive care was only 3.68% (BMD test, 1.46%; osteoporosis medications, 1.65%; calcium/vitamin D, 1.63%). Increasing age (OR = 2.53, p < 0.001; 40–49 years, OR = 3.99, p < 0.001; 50–59 years, OR = 5.17, p < 0.001; 60–69 years, OR = 8.07, p < 0.001; ≥70 years, respectively), systemic autoimmune disease (OR = 3.08, p < 0.001), rural residence (OR = 1.19, p = 0.046), concomitant hyperthyroidism (OR = 1.58, p = 0.007), and malignancy (OR = 1.59, p < 0.001) were significantly associated with a higher likelihood of receiving high-quality GIOP preventive care. Male sex (OR = 0.26, p < 0.001) and GC prescription in primary care clinics and nursing hospitals (OR = 0.66, p < 0.001) were associated with a lower rate of high-quality GIOP preventive care. Conclusions: Most Korean patients treated with GC did not receive appropriate preventive care for GIOP in real-world practice. More efforts are needed by clinicians to prevent, screen, and treat GIOP.
Collapse
Affiliation(s)
- Byung-Wook Song
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan 49241, Korea; (B.-W.S.); (A.-R.K.)
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Korea
| | - A-Ran Kim
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan 49241, Korea; (B.-W.S.); (A.-R.K.)
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Korea
| | - Min-A Kim
- Department of Data Science, Hanmi Pharm. Co., Ltd., Seoul 05545, Korea; (M.-A.K.); (H.-S.K.)
| | - Ho-Seob Kim
- Department of Data Science, Hanmi Pharm. Co., Ltd., Seoul 05545, Korea; (M.-A.K.); (H.-S.K.)
| | - Seung-Geun Lee
- Division of Rheumatology, Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan 49241, Korea; (B.-W.S.); (A.-R.K.)
- Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Korea
- Correspondence:
| |
Collapse
|
5
|
Hayes KN, Burden AM, Winter EM, Hauser B. Comment on: Paradoxically protective effect of glucocorticoids on bone mass and fragility fracture in a large cohort: a cross-sectional study. Rheumatol Adv Pract 2022; 6:rkac010. [PMID: 35531047 PMCID: PMC9073364 DOI: 10.1093/rap/rkac010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/07/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kaleen N Hayes
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrea M Burden
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | - Elizabeth M Winter
- Center for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Barbara Hauser
- Rheumatic Disease Unit, Western General Hospital, NHS Lothian
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
6
|
[Drug-induced osteopathy in rheumatology]. Z Rheumatol 2022; 81:189-197. [PMID: 35006380 DOI: 10.1007/s00393-021-01145-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
Osteopathy in rheumatology can either be primary a condition as a consequence of inflammatory rheumatic diseases but can also be drug induced. The most severe clinical manifestations are insufficiency fractures and osteonecrosis. The risk of fractures is highest for patients treated with glucocorticoids depending on the daily intake, the cumulative glucocorticoid dosage and the duration of administration. An incidence rate of nearly 13% was reported after administration of glucocorticoids lasting > 1 year. Cases of osteonecrosis under glucocorticoids are, in contrast, less frequent and not associated with glucocorticoid-induced osteoporosis. The antiresorptive substances bisphosphonates and denosumab, as well as romosumab are effective and important in treating osteoporosis; however, they can also cause atypical fractures, particularly of the femur as well as osteonecrosis of the jawbone. According to the most recent guidelines the benefits of bisphosphonate treatment have only been verified for 3-5 years and for denosumab for 3 years. There are clear preventive recommendations to avoid osteonecrosis of the jaw. Ultimately, the disease-modifying antirheumatic drugs (DMARD) methotrexate and leflunomide also affect the metabolism of bones. There is a rare but very characteristic form of osteopathy associated with methotrexate, mainly occurring in cases of long-term treatment. The typical manifestations are insufficiency fractures, particularly of the distal tibia, which persist for many years under continuous methotrexate administration. The treatment is the discontinuation of methotrexate and in most cases the fractures will heal within 3-4 months. Leflunomide has been associated with cases of persisting pseudarthrosis that only disappeared after a wash-out of the active metabolite.
Collapse
|
7
|
Leipe J, Holle JU, Weseloh C, Pfeil A, Krüger K. German Society of Rheumatology recommendations for management of glucocorticoid-induced osteoporosis. Z Rheumatol 2021; 80:49-63. [PMID: 34705070 DOI: 10.1007/s00393-021-01025-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Glucocorticoids are of substantial therapeutic importance in the treatment of inflammatory diseases, but are also associated with bone mineral density loss, osteoporosis, and fractures, especially with long-term use. OBJECTIVE To develop recommendations for the management of glucocorticoid-induced osteoporosis (GIOP) in adult patients on long-term glucocorticoid (GC) treatment. METHODS A systematic literature search (SLR) was conducted to synthesize the evidence for GIOP prevention and treatment options. Recommendations were developed based on SLR/level of evidence and by previously defined questions and in a structured group consensus process. RESULTS Recommendations include supplementation with calcium and vitamin D under long-term GC therapy in adults. If specific osteologic treatment is indicated, we recommend bisphosphonates or denosumab as first-line treatment. If fracture risk is high, we recommend teriparatide as primary specific osteologic treatment. Denosumab should be used in cases of severe renal insufficiency, and specific osteologic treatment should not be given in pregnancy. For patients who have not reached the treatment goal, a switch to another class of specific osteologic drugs should be performed. We recommend re-evaluation after a treatment duration of 3-5 years or after termination of long-term GC treatment. CONCLUSION This work aims to provide evidence-based and consensus-based recommendations for the best possible management of GIOP in Germany and to support treatment decisions.
Collapse
Affiliation(s)
- Jan Leipe
- Division of Rheumatology, Department of Medicine V, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany. .,Division of Rheumatology and Clinical Immunology, Medizinische Klinik and Poliklinik IV, University of Munich, Munich, Germany.
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Germany
| | - Christiane Weseloh
- German Society of Rheumatology (Deutsche Gesellschaft für Rheumatologie, DGRh), Berlin, Germany
| | - Alexander Pfeil
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Klaus Krüger
- Rheumatologisches Praxiszentrum München, Munich, Germany
| |
Collapse
|
8
|
Leipe J, Holle JU, Weseloh C, Pfeil A, Krüger K. [German Society of Rheumatology Recommendations for the management of glucocorticoid-induced Osteoporosis. German version]. Z Rheumatol 2021; 80:670-687. [PMID: 34357436 DOI: 10.1007/s00393-021-01028-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Glucocorticoids are of substantial therapeutic importance in the treatment of inflammatory diseases, but are also associated with bone mineral density loss, osteoporosis, and fractures, especially with long-term use. OBJECTIVE To develop recommendations for the management of glucocorticoid-induced osteoporosis (GIOP) in adult patients on long-term glucocorticoid (GC) treatment. METHODS A systematic literature search (SLR) was conducted to synthesize the evidence for GIOP prevention and treatment options. Recommendations were developed based on SLR/level of evidence and by previously defined questions and in a structured group consensus process. RESULTS Recommendations include supplementation with calcium and vitamin D under long-term GC therapy in adults. If specific osteologic treatment is indicated, we recommend bisphosphonates or denosumab as first-line treatment. If fracture risk is high, we recommend teriparatide as primary specific osteologic treatment. Denosumab should be used in cases of severe renal insufficiency, and specific osteologic treatment should not be given in pregnancy. For patients who have not reached the treatment goal, a switch to another class of specific osteologic drugs should be performed. We recommend re-evaluation after a treatment duration of 3-5 years or after termination of long-term GC treatment. CONCLUSION This work aims to provide evidence-based and consensus-based recommendations for the best possible management of GIOP in Germany and to support treatment decisions.
Collapse
Affiliation(s)
- Jan Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätskrankenhaus Mannheim, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland. .,Sektion Rheumatologie und Klinische Immunologie, Medizinische Klinik IV, Ludwig-Maximilians-Universität München, München, Deutschland.
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumünster, Deutschland
| | | | - Alexander Pfeil
- Klinik für Innere Medizin III, Funktionsbereich Rheumatologie, Universitätsklinikum Jena, Jena, Deutschland
| | - Klaus Krüger
- Rheumatologisches Praxiszentrum München, München, Deutschland
| | | |
Collapse
|
9
|
Evaluation of care delivery by a novel multidisciplinary bone health clinic for patients at risk of glucocorticoid-induced osteoporosis. Arch Osteoporos 2021; 16:108. [PMID: 34347188 DOI: 10.1007/s11657-021-00979-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/18/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED Glucocorticoid-induced osteoporosis (GIOP) is a common condition associated with increased risk for fracture. Many patients receive suboptimal care. We created a novel GIOP clinic model which successfully fills a gap in osteoporosis care by providing multidisciplinary intervention in key components of GIOP preventive care to an underserved patient population. INTRODUCTION This study characterizes the patient population referred to our novel glucocorticoid-induced osteoporosis (GIOP) clinic and evaluates how well the clinic performed in addressing key components of GIOP preventive care. METHODS This population-based prospective cohort study derives data from patients reviewed at the University of Alberta Multidisciplinary Bone Health Clinic from January 2017 to September 2019. To create our clinic model, key components of GIOP preventive care were summarized based on current guidelines, and clear responsibilities were delegated to each multidisciplinary team member. A REDCap database was constructed, and each patient's multidisciplinary assessment was entered at each visit. Demographic and treatment data was extracted from our database. RESULTS The clinic was able to achieve optimal GIOP preventive care in 60.1% of patients and in 78.7% of patients when excluding wait time. Of the 245 GIOP patients assessed, over half were females (56.7%) and the mean age was 56.7 years (range 16-95 years). Referrals were primarily made by specialists. Low-trauma fractures were reported in 24.9% of patients and 95.5% of patients had a baseline dual-energy X-ray absorptiometry (DXA). The mean current daily prednisone-equivalent dose was 14.1 mg. All patients received a recommendation for pharmacotherapy (100%) and the majority received counseling on vitamin D (98.8%), calcium (97.8%), smoking cessation (98.8%), alcohol reduction (98.4%), falls prevention (88.6%), and exercise (85.3%). CONCLUSION Our novel GIOP clinic model successfully fills a gap in osteoporosis care by providing multidisciplinary intervention in key components of GIOP preventive care to an underserved patient population. Further studies are required to assess the real-world long-term outcomes of our model.
Collapse
|
10
|
Hayes KN, Baschant U, Hauser B, Burden AM, Winter EM. When to Start and Stop Bone-Protecting Medication for Preventing Glucocorticoid-Induced Osteoporosis. Front Endocrinol (Lausanne) 2021; 12:782118. [PMID: 34975756 PMCID: PMC8715727 DOI: 10.3389/fendo.2021.782118] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/19/2021] [Indexed: 01/28/2023] Open
Abstract
Glucocorticoid-induced osteoporosis (GIOP) leads to fractures in up to 40% of patients with chronic glucocorticoid (GC) therapy when left untreated. GCs rapidly increase fracture risk, and thus many patients with anticipated chronic GC exposures should start anti-osteoporosis pharmacotherapy to prevent fractures. In addition to low awareness of the need for anti-osteoporosis therapy among clinicians treating patients with GCs, a major barrier to prevention of fractures from GIOP is a lack of clear guideline recommendations on when to start and stop anti-osteoporosis treatment in patients with GC use. The aim of this narrative review is to summarize current evidence and provide considerations for the duration of anti-osteoporosis treatment in patients taking GCs based on pre-clinical, clinical, epidemiologic, and pharmacologic evidence. We review the pathophysiology of GIOP, outline current guideline recommendations on initiating and stopping anti-osteoporosis therapy for GIOP, and present considerations for the duration of anti-osteoporosis treatment based on existing evidence. In each section, we illustrate major points through a patient case example. Finally, we conclude with proposed areas for future research and emerging areas of interest related to GIOP clinical management.
Collapse
Affiliation(s)
- Kaleen N. Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Ulrike Baschant
- Division of Endocrinology, Diabetes and Bone Diseases, Department of Medicine III and Center for Healthy Aging, Technische Universität Dresden, Dresden, Germany
- *Correspondence: Ulrike Baschant,
| | - Barbara Hauser
- Rheumatic Disease Unit, Western General Hospital, National Health Service (NHS) Lothian, Edinburgh, United Kingdom
- Rheumatology and Bone Disease Unit, Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrea M. Burden
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, Swiss Federal Institute of Technology [Eidgenössische Technische Hochschule (ETH)] Zurich, Zurich, Switzerland
| | - Elizabeth M. Winter
- Center for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
11
|
Apalset EM, Lunde A, Hoff M, Ehrenstein V, Tell GS. Initiation of anti-osteoporotic drugs in high-risk female patients starting glucocorticoid treatment: a population study in Norway. Arch Osteoporos 2020; 15:121. [PMID: 32757143 PMCID: PMC7406535 DOI: 10.1007/s11657-020-00783-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 07/01/2020] [Indexed: 02/03/2023]
Abstract
Glucocorticoid use is a risk factor for osteoporosis and fractures. We studied whether women initiating glucocorticoid treatment also started anti-osteoporotic treatment, according to clinical guidelines. Women with versus without previous fracture were twice as likely to start anti-osteoporotic treatment within 1 year after initiating glucocorticoid treatment, but the cumulative incidences were low 9.1% vs. 4.6%, respectively. PURPOSE Use of glucocorticoids (GC) is a risk factor for osteoporosis and fractures, and clinical guidelines suggest that preventive treatment with anti-osteoporotic drugs (AOD) should be considered when starting GC. Women with high risk of osteoporosis comprise those with previous fractures or a known inflammatory rheumatic disease, for whom the indication of AOD is even stronger. The purpose of these analyses was to investigate whether women initiating GC treatment also started AOD, especially those with high risk of osteoporosis. METHODS We used data from the Norwegian Prescription Database to identify all women 55 years and older initiating GC treatment in Norway during 2010-2016 and to obtain information on use of AOD. Data from the Norwegian Patient Registry were used to obtain information on previous fractures and diagnoses. RESULTS Among 105,477 women initiating GC treatment during 2010-2016, 3256 had started AOD and 79,638 had discontinued GC treatment after 1-year follow-up. Cumulative incidence of starting AOD after 1 year was 9.1% (95% CI: 7.9, 10.4) for women with vs. 4.6% (95% CI: 4.4%, 4.8%) for women without a previous fracture. Women with rheumatoid arthritis or another inflammatory rheumatic disease were more likely to start AOD than women with other indications. For the whole cohort, the probability of starting AOD treatment within 1 year after initiating GC increased on average 3% per year (HR = 1.03, CI: 1.01, 1.05) from 2010 to 2016. CONCLUSIONS Having had a previous fracture or an inflammatory rheumatic disease increased the probability of treatment with AOD. However, the proportions starting AOD were much lower than clinically indicated.
Collapse
Affiliation(s)
- Ellen M Apalset
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, N-5018, Bergen, Norway
- Bergen Group of Epidemiology and Biomarkers in Rheumatic Disease, Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | - Astrid Lunde
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, N-5018, Bergen, Norway.
| | - Mari Hoff
- Department of Neuromedicine and Movement Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Public Health and Nursing, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Rheumatology, St. Olavs University Hospital, Trondheim, Norway
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Grethe S Tell
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, N-5018, Bergen, Norway
| |
Collapse
|
12
|
Chotiyarnwong P, McCloskey EV. Pathogenesis of glucocorticoid-induced osteoporosis and options for treatment. Nat Rev Endocrinol 2020; 16:437-447. [PMID: 32286516 DOI: 10.1038/s41574-020-0341-0] [Citation(s) in RCA: 219] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 12/31/2022]
Abstract
Glucocorticoids are widely used to suppress inflammation or the immune system. High doses and long-term use of glucocorticoids lead to an important and common iatrogenic complication, glucocorticoid-induced osteoporosis, in a substantial proportion of patients. Glucocorticoids mainly increase bone resorption during the initial phase (the first year of treatment) by enhancing the differentiation and maturation of osteoclasts. Glucocorticoids also inhibit osteoblastogenesis and promote apoptosis of osteoblasts and osteocytes, resulting in decreased bone formation during long-term use. Several indirect effects of glucocorticoids on bone metabolism, such as suppression of production of insulin-like growth factor 1 or growth hormone, are involved in the pathogenesis of glucocorticoid-induced osteoporosis. Fracture risk assessment for all patients with long-term use of oral glucocorticoids is required. Non-pharmacological interventions to manage the risk of fracture should be prescribed to all patients, while pharmacological management is reserved for patients who have increased fracture risk. Various treatment options can be used, ranging from bisphosphonates to denosumab, as well as teriparatide. Finally, appropriate monitoring during treatment is also important.
Collapse
Affiliation(s)
- Pojchong Chotiyarnwong
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Academic Unit of Bone Metabolism, Department of Oncology and Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK
| | - Eugene V McCloskey
- Academic Unit of Bone Metabolism, Department of Oncology and Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK.
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK.
- Centre for Integrated Research into Musculoskeletal Ageing, University of Sheffield Medical School, Sheffield, UK.
| |
Collapse
|
13
|
Sapkota S, Baig S, Hess T, O'Connell AM, Menk J, Shyne M, Fazeli P, Ensrud K, Shmagel A. Vitamin D and bisphosphonate therapy in systemic lupus erythematosus patients who receive glucocorticoids: are we offering the best care? Lupus 2020; 29:263-272. [PMID: 31996109 DOI: 10.1177/0961203320903086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study aimed to evaluate management practices for glucocorticoid (GC)-induced osteoporosis (GIOP) in systemic lupus erythematosus (SLE) patients using 2017 American College of Rheumatology guidelines as a gold standard. METHODS We conducted a retrospective cohort study using a clinical database from the years 2011 to 2016. SLE cases with >90 days continuous prednisone use at doses of ≥7.51 mg daily were identified. Osteoporosis risk factors were assessed via chart review. The Fracture Risk Assessment (FRAX) score was estimated for patients > 40 years of age. Vitamin D, bisphosphonate prescriptions, and osteoporotic (OP) fractures were ascertained through chart review. A classification tree was used to identify the key patient-related predictors of bisphosphonate prescription. RESULTS A total of 203 SLE patients met the inclusion criteria. The recommended dose of vitamin D supplement was prescribed to 58.9% of patients < 40 years of age and 61.5% of patients ≥ 40 years of age. Among patients aged ≥ 40 years, 25% were prescribed bisphosphonates compared to 36% who met indications for bisphosphonates per the ACR guidelines. Another 10% were prescribed a bisphosphonate, despite not having indication per the ACR guidelines, which was considered as overtreatment. Among patients aged ≥ 40 years, older age and a higher FRAX score for major OP fracture and hip fracture predicted bisphosphonate prescription. In a classification tree analysis, patients with FRAX scores (for major OP fracture) of ≥ 23.5% predicted bisphosphonate prescription in this SLE population. Among patients who had OP fractures in the follow-up period, nine (6.50%) were inpatients receiving appropriate GIOP care versus 12 (13.6%) who were inpatients not receiving ACR-appropriate care (p = 0.098). CONCLUSIONS In clinical practice, fewer SLE patients with or at risk for GIOP are prescribed vitamin D and bisphosphonates than recommended by the 2017 ACR guidelines. Also, in this study, another 10% were prescribed a bisphosphonate, despite not having an indication per the ACR guidelines. Patients were most likely to receive a bisphosphonate prescription if they had a major OP FRAX score of > 23.5%.
Collapse
Affiliation(s)
- S Sapkota
- Department of Medicine, University of Minnesota, Minneapolis, USA.,Division of General Internal Medicine, University of Minnesota, Minneapolis, USA
| | - S Baig
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - T Hess
- University of Minnesota Medical School, University of Minnesota, Minneapolis, USA
| | | | - J Menk
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, USA
| | - M Shyne
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, USA
| | - P Fazeli
- Department of Medicine, University of Minnesota, Minneapolis, USA.,Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, USA
| | - K Ensrud
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, USA.,Center for Care Delivery and Outcome Research, Minneapolis VA Health Care System, Minneapolis, USA
| | - A Shmagel
- Department of Medicine, University of Minnesota, Minneapolis, USA.,Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, USA
| |
Collapse
|
14
|
Koller G, Katz S, Charrois TL, Ye C. Glucocorticoid-induced osteoporosis preventive care in rheumatology patients. Arch Osteoporos 2019; 14:16. [PMID: 30723883 DOI: 10.1007/s11657-019-0570-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/27/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED Glucocorticoid-induced osteoporosis (GIOP) is common in patients prescribed with long-term glucocorticoids. Guidelines suggest patients receiving moderate-dose glucocorticoid therapy receive GIOP preventive care. Previous studies have shown preventive care rates are not optimal. We look at GIOP preventive care rates in rheumatology patients and predictors of various components of care. PURPOSE Glucocorticoid-induced osteoporosis (GIOP) is a common concern in patients prescribed with long-term glucocorticoids. Studies have shown GIOP preventive care is not provided optimally in the general population; however, little is published on GIOP preventive care among patients with rheumatic disease. The objective of this study is to determine the proportion of rheumatology patients who received GIOP preventive care. METHODS A population-based retrospective quality assurance study of adults seen at the University of Alberta Rheumatology Clinic was performed using the electronic outpatient medical record. Records of adult patients prescribed with prednisone from January 1st to December 31st, 2016 by a rheumatologist were initially included for review. Those who had been prescribed ≥ 7.5 mg/day for ≥ 3 months were assessed for concurrent GIOP preventive care. RESULTS A total of 745 discreet courses of prednisone were prescribed in 433 patients with 113 meeting the above inclusion criteria. Following the prednisone prescription, 79% were taking vitamin D, 86% were taking calcium, and 50% were prescribed with osteoporosis pharmacotherapy. Twenty-five percent of patients had DXA imaging ordered by the rheumatologist within the first 6 months; of these, 86% of patients completed the DXA. CONCLUSIONS Overall, our study shows that patients under the care of rheumatologists receive better GIOP preventative care than previously reported care in the general population. However, there is still room for improvement. In particular, men, younger patients, and rural patients seem to be at the most at risk of not receiving optimal GIOP prevention.
Collapse
Affiliation(s)
- G Koller
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - S Katz
- Department of Medicine, Division of Rheumatology, University of Alberta, 8-130 Clinical Sciences Building, 11350 83rd Avenue NW, Edmonton, AB, T6G 2G3, Canada
| | - T L Charrois
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - C Ye
- Department of Medicine, Division of Rheumatology, University of Alberta, 8-130 Clinical Sciences Building, 11350 83rd Avenue NW, Edmonton, AB, T6G 2G3, Canada.
| |
Collapse
|
15
|
Balasubramanian A, Wade SW, Adler RA, Saag K, Pannacciulli N, Curtis JR. Glucocorticoid Exposure and Fracture Risk in a Cohort of US Patients With Selected Conditions. J Bone Miner Res 2018; 33:1881-1888. [PMID: 29924418 DOI: 10.1002/jbmr.3523] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 06/05/2018] [Accepted: 06/07/2018] [Indexed: 11/07/2022]
Abstract
The purpose of this work was to evaluate systemic glucocorticoid exposure and fracture among patients with newly-diagnosed inflammatory and immune-modulated conditions. Using administrative data, inception cohorts of rheumatoid arthritis (RA), asthma/chronic obstructive pulmonary disease (COPD), inflammatory bowel disease (IBD), multiple sclerosis (MS), lupus, and sarcoidosis patients age 18 to 64 years with benefits coverage ≥12 months before diagnosis (January 1, 2005 to December 31, 2012) were followed to clinical fracture, cancer diagnosis, or December 31, 2012. Glucocorticoid users were new to therapy. Fracture incidence rates (IRs) per 1000 person-years were stratified by prednisone equivalent doses. Cox's proportional hazards models assessed risk by daily and cumulative dose, and by time since discontinuation, adjusted for baseline characteristics. Most patients (72% of 403,337) had glucocorticoid exposure; 52% were under age 50. IR (95% confidence interval [CI]) of any osteoporotic fracture was elevated at doses <5 mg/day (IR 9.33; 95% CI, 7.29 to 11.77) versus 0 mg/day (IR 4.87 (95% CI, 4.72 to 5.02). Fracture rates were elevated at doses <5 mg/day in patients <50 years and those ≥50 years. In both age groups, fracture risk increased with increasing cumulative exposure, being approximately 2.5-fold higher at cumulative dose ≥5400 mg compared to <675 mg. At ≥5400 mg, IR values were 5.69 (95% CI, 4.32 to 7.35) in patients <50 years and 17.10 (95% CI, 14.97 to 19.46) in older patients. Fracture risk decreased significantly within months following glucocorticoid discontinuation. In patients with a variety of inflammatory conditions, fracture risk increased at doses as low as <5 mg/day. Risk increased with increasing cumulative exposure and decreased soon following glucocorticoid discontinuation. Trends were similar between patients older and younger than 50 years. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals, Inc.
Collapse
Affiliation(s)
| | - Sally W Wade
- Wade Outcomes Research and Consulting, Salt Lake City, UT, USA
| | - Robert A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University, Richmond, VA, USA
| | - Kenneth Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
16
|
Jagpal A, Saag KG. Glucocorticoid-Induced Osteoporosis: Update on Management. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2018. [DOI: 10.1007/s40674-018-0105-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
17
|
Desai RJ, Mahesri M, Abdia Y, Barberio J, Tong A, Zhang D, Mavros P, Kim SC, Franklin JM. Association of Osteoporosis Medication Use After Hip Fracture With Prevention of Subsequent Nonvertebral Fractures: An Instrumental Variable Analysis. JAMA Netw Open 2018; 1:e180826. [PMID: 30646034 PMCID: PMC6324295 DOI: 10.1001/jamanetworkopen.2018.0826] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
IMPORTANCE Osteoporosis medication treatment is recommended after hip fracture, yet contemporary estimates of rates of initiation and clinical benefit in the patient population receiving routine care are not well documented. OBJECTIVES To report osteoporosis treatment initiation rates between January 1, 2004, and September 30, 2015, and to estimate the risk reduction in subsequent nonvertebral fractures associated with treatment initiation in patients with hip fracture. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, data from a commercial insurance claims database from the United States were analyzed. Patients 50 years and older who had a hip fracture and were not receiving treatment with osteoporosis medications before their fracture were included. EXPOSURE Prescription dispensing of an osteoporosis medication within 180 days of a hip fracture hospitalization. MAIN OUTCOMES AND MEASURES Each initiation episode was matched with 10 nonuse episodes on person-time after the index hip fracture event to preclude immortal time bias and followed up for the outcome of nonvertebral fracture until change in exposure or a censoring event. An instrumental variable analysis using 2-stage residual inclusion method was conducted using calendar year, specialist access, geographical variation in prescribing patterns, and hospital preference. RESULTS Among 97 169 patients with a hip fracture identified, the mean (SD) age was 80.2 (10.8) years, and 64 164 (66.0%) were women. A continuous decline over the study years was observed in osteoporosis medication initiation rates from 9.8% (95% CI, 9.0%-10.6%) in 2004 to 3.3% (95% CI, 2.9%-3.8%) in 2015. In the effectiveness analyses, the hospital preference instrumental variable had a stronger association with treatment (pseudo R2 = 0.20) than the other 3 instrumental variables (specialist access: pseudo R2 = 0.04; calendar year: pseudo R2 = 0.05; and geographic variation: pseudo R2 = 0.07). Instrumental variable analysis with hospital preference suggested a rate difference of 4.2 events (95% CI, 1.1-7.3) per 100 person-years in subsequent fractures associated with osteoporosis treatment initiation compared with nonuse in an additive hazard model. CONCLUSIONS AND RELEVANCE Low rates of osteoporosis treatment initiation after a hip fracture in recent years were observed. Clinically meaningful reduction in subsequent nonvertebral fracture rates associated with treatment suggests that improving prescriber adherence to guidelines and patient adherence to prescribed regimens may result in notable public health benefit.
Collapse
Affiliation(s)
- Rishi J. Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Younathan Abdia
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julie Barberio
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Angela Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Seoyoung C. Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jessica M. Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
18
|
Suda M, Suyama Y, Ohde S, Tsuda T, Sawada H, Kishimoto M, Okada M. Effects of quality indicator monitoring for glucocorticoid-induced osteoporosis and trends of drug treatment in a Japanese hospital. Int J Rheum Dis 2018; 21:975-981. [PMID: 29878618 DOI: 10.1111/1756-185x.13310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AIMS Globally, the appropriate prescription rate for glucocorticoid-induced osteoporosis (GIOP) is low. Thus, we aimed to examine the improvement in real-world GIOP care using a hospital-wide systematic approach with quality indicator (QI) monitoring. METHODS We defined a novel QI for GIOP care for the prescription rate of anti-osteoporotic drugs according to 2010 American College of Rheumatology GIOP management recommendations, with the target being patients prescribed ≥7.5 mg prednisolone daily or its equivalent for ≥3 months. We monitored the glucocorticoid and osteoporotic medication dose for all patients who visited our hospital. From May 2011, we began interventions to improve QI: monthly QI monitoring providing QI-trend feedback to each department in a hospital-wide QI meeting every 3 months and organizing lectures on GIOP. We retrospectively analyzed QI trends from 2010 to 2013. We categorized groups by sex and age for subanalyses: group A, men; group B, women, aged <50 years; group C, women, aged ≥50 years. RESULTS The numbers of participants were 401, 420, 520 and 513 in 2010, 2011, 2012 and 2013, respectively, with pooled QI rates of 45.8%, 51.3%, 55.0% and 54.8%, respectively. Changes in QI between each consecutive 2 years were statistically significant. Subanalyses showed statistically significant QI improvements in groups A and C. We observed a decreasing trend of daily bisphosphonate use throughout the study period, especially at the Immuno-Rheumatology Center. CONCLUSIONS Quality indicator monitoring for GIOP significantly improved appropriate anti-osteoporotic drug prescriptions, especially in men and postmenopausal women.
Collapse
Affiliation(s)
- Masei Suda
- Immuno-Rheumatology Center, St. Luke's International Hospital, St. Luke's International University, Tokyo, Japan
| | - Yasuhiro Suyama
- Immuno-Rheumatology Center, St. Luke's International Hospital, St. Luke's International University, Tokyo, Japan
| | - Sachiko Ohde
- Graduate School of Public Health, St. Luke's International University, OMURA Susumu & Mieko Memorial St. Luke's Center for Clinical Academia, Tokyo, Japan
| | - Tokutaro Tsuda
- Immuno-Rheumatology Center, St. Luke's International Hospital, St. Luke's International University, Tokyo, Japan
| | - Haruki Sawada
- Immuno-Rheumatology Center, St. Luke's International Hospital, St. Luke's International University, Tokyo, Japan
| | - Mitsumasa Kishimoto
- Immuno-Rheumatology Center, St. Luke's International Hospital, St. Luke's International University, Tokyo, Japan
| | - Masato Okada
- Immuno-Rheumatology Center, St. Luke's International Hospital, St. Luke's International University, Tokyo, Japan
| |
Collapse
|
19
|
Ozen G, Kamen DL, Mikuls TR, England BR, Wolfe F, Michaud K. Trends and Determinants of Osteoporosis Treatment and Screening in Patients With Rheumatoid Arthritis Compared to Osteoarthritis. Arthritis Care Res (Hoboken) 2018; 70:713-723. [PMID: 28771973 PMCID: PMC5797515 DOI: 10.1002/acr.23331] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/25/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To profile osteoporosis (OP) care in patients with rheumatoid arthritis (RA) over the past decade. METHODS Patients with RA or osteoarthritis (OA) were followed from 2003 through 2014. OP care was defined as receipt of OP treatment (with the exception of calcium/vitamin D) or screening (OPTS). Adjusted trends over followup, and the factors associated with OP care, were examined using multivariable Cox proportional hazards. RESULTS OPTS was reported in 67.4% of 11,669 RA patients and in 64.6% of 2,829 OA patients during a median (interquartile range) 5.5 (2-9) years of followup. In patients for whom treatment was recommended by the 2010 American College of Rheumatology (ACR) glucocorticoid-induced OP (GIOP) guidelines (48.4% of RA patients and 17.6% of OA patients), approximately 55% overall reported OP medication use. RA patients were not more likely to undergo OPTS compared to OA patients (hazard ratio 1.04 [95% confidence interval 0.94-1.15]). Adjusted models showed a stable trend for OPTS between 2004 and 2008 compared to 2003, with a significant downward trend after 2008 in both RA and OA patients. Factors associated with receipt of OP care in RA patients were older age, postmenopausal state, prior fragility fracture or diagnosis of OP, any duration of glucocorticoid treatment, and use of biologic agents. CONCLUSION Approximately half of RA patients for whom treatment was indicated never received an OP medication. OP care in RA patients was not better than in OA patients, and the relative risk of the application of this care has been decreasing in RA and OA patients since 2008 without improvement after the release of the 2010 ACR GIOP guideline.
Collapse
Affiliation(s)
- Gulsen Ozen
- University of Nebraska Medical Center, Omaha, NE
- Marmara University, Faculty of Medicine, Istanbul, Turkey
| | - Diane L Kamen
- Medical University of South Carolina, Charleston, SC
| | - Ted R Mikuls
- University of Nebraska Medical Center, Omaha, NE
- Veterans Affairs (VA) Nebraska-Western Iowa Health Care System, Omaha, NE
| | - Bryant R England
- University of Nebraska Medical Center, Omaha, NE
- Veterans Affairs (VA) Nebraska-Western Iowa Health Care System, Omaha, NE
| | | | - Kaleb Michaud
- University of Nebraska Medical Center, Omaha, NE
- National Data Bank for Rheumatic Diseases, Wichita, KS
| |
Collapse
|
20
|
Amiche MA, Abtahi S, Driessen JHM, Vestergaard P, de Vries F, Cadarette SM, Burden AM. Impact of cumulative exposure to high-dose oral glucocorticoids on fracture risk in Denmark: a population-based case-control study. Arch Osteoporos 2018; 13:30. [PMID: 29552730 PMCID: PMC5857556 DOI: 10.1007/s11657-018-0424-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/03/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED We examined the effect of cumulative exposure to high doses of oral glucocorticoids on fracture risk. Compared to short-course users (daily dose ≥ 15 mg + cumulative < 1 g), heavy users (daily dose ≥ 15 mg + cumulative dose ≥ 1 g) had the highest risk of fracture. These patients should be monitored for fracture management strategies. PURPOSE The effect of cumulative exposure to high daily doses of oral glucocorticoids on fracture risk remains debated. We therefore aimed to examine the hip fracture risk associated with short courses and heavy use of high-dosed oral glucocorticoids. METHODS We conducted a population-based case-control study using the Danish National Health Service data, 1996-2011. Cases were those aged ≥ 18 years who sustained a hip (primary outcome) fracture (n = 81,342). Vertebral and forearm fractures were considered in secondary analyses. Controls (matched 1:1) were those without a fracture. Average daily dose (DD) and total cumulative dose (CD) were calculated among current oral glucocorticoid users. Among patients with a high daily dose (DD ≥ 15 mg), we identified short-course users as those with a CD < 1 g and heavy users as those with a CD ≥ 1 g. We estimated adjusted odds ratio (adj.OR) of fracture with current glucocorticoid use compared to never-use, using conditional logistic regression. RESULTS A high DD (≥ 15 mg) and high CD (≥ 1 g) were independently associated with an increased hip fracture risk (adj.OR 2.5; 95% CI 2.2-2.9; adj.OR 1.6; 95% CI 1.5-1.8, respectively). However, the risk was substantially increased among heavy users (DD ≥ 15 mg and CD ≥ 1 g: adj.OR 2.9; 95% CI 2.5-3.4) as compared to short-course users (DD ≥ 15 mg and CD < 1 g: adj.OR 1.4; 95% CI 1.1-1.9). Associations were stronger for vertebral fractures, yet little association was identified for forearm fractures. CONCLUSION Among patients receiving a high DD (≥ 15 mg), heavy users (≥ 1 g CD) showed the most substantial increase in hip fracture risk. Among those receiving high DD, a threshold of 1 g CD may identify heavy users that are candidates for focused fracture management services.
Collapse
Affiliation(s)
- M. Amine Amiche
- 0000 0001 2157 2938grid.17063.33Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
| | - Shahab Abtahi
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands
| | - Johanna H. M. Driessen
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands ,0000000120346234grid.5477.1Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands ,0000 0001 0481 6099grid.5012.6NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Peter Vestergaard
- 0000 0001 0742 471Xgrid.5117.2Department of Clinical Medicine, Aalborg University, Aalborg, Denmark ,0000 0004 0646 7349grid.27530.33Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Frank de Vries
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands ,0000000120346234grid.5477.1Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Suzanne M. Cadarette
- 0000 0001 2157 2938grid.17063.33Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
| | - Andrea M. Burden
- 0000 0004 0480 1382grid.412966.eDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute (CAPHRI), Maastricht, The Netherlands ,0000000120346234grid.5477.1Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
21
|
Affiliation(s)
- Kripa Elizabeth Cherian
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
| | - Thomas Vizhalil Paul
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
22
|
Rizzoli R. Towards a better management of glucocorticoid-induced osteoporosis? Nat Rev Rheumatol 2017; 13:635-636. [DOI: 10.1038/nrrheum.2017.141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
23
|
Balasubramanian A, Wade SW, Adler RA, Lin CJF, Maricic M, O'Malley CD, Saag K, Curtis JR. Glucocorticoid exposure and fracture risk in patients with new-onset rheumatoid arthritis. Osteoporos Int 2016; 27:3239-3249. [PMID: 27273113 DOI: 10.1007/s00198-016-3646-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 05/19/2016] [Indexed: 01/30/2023]
Abstract
UNLABELLED Retrospective claims analysis indicated that high levels of daily and cumulative doses of systemic glucocorticoids were associated with elevated fracture risk in a large cohort of new RA patients under age 65. Heightened risk began to decline within months of discontinuation. Findings were similar among patients age <50 years. INTRODUCTION We evaluated the impact of systemic glucocorticoid exposure on fracture risk among relatively young patients with new-onset rheumatoid arthritis (RA). METHODS Using administrative data, we identified 42,127 RA patients diagnosed January 1, 2005-December 31, 2012, age 18-64 years, with benefits coverage for ≥12 months before RA diagnosis. Follow-up extended to clinical fracture, cancer diagnosis, or December 31, 2012. Glucocorticoid users were new to therapy. Fracture incidence rates (IR) were stratified by glucocorticoid exposure expressed as prednisone equivalent doses. Cox's proportional hazards models estimated fracture risk adjusted for demographics and baseline clinical characteristics to assess dose-response relationships with current (daily) and prior (cumulative) dose, and by time since discontinuation. RESULTS Most patients (85 %) had glucocorticoid exposure. Exposed and unexposed patients were demographically similar (74 % female; mean age 49.7 and 48.8 years); 1 % had prior fracture. Fracture IRs (95 % confidence intervals) were 5 to 9 per 1000 person-years at doses <15 mg/day, 16.0 (11.0, 22.6) at doses ≥15 mg/day, and 13.4 (10.7, 16.7) at cumulative doses ≥5400 mg. Adjusted fracture risk was approximately 2-fold higher at highest dose levels compared with 0 mg/day current daily dose and <675 mg cumulative dose, respectively. Fracture risk was 29 % lower at 60-182 days post-discontinuation compared with ongoing use and was similar to unexposed patients by 12 months. Findings were similar among patients age <50 years. CONCLUSIONS Among younger, new-onset RA patients, fracture risk was significantly elevated at high levels of daily and cumulative dose, and was similar to unexposed patients by 12 months post-discontinuation.
Collapse
Affiliation(s)
| | - S W Wade
- Wade Outcomes Research and Consulting, 358 South 700 East, Suite B-432, Salt Lake City, UT, USA.
| | - R A Adler
- McGuire Veterans Affairs Medical Center and Virginia Commonwealth University, Richmond, VA, USA
| | - C J F Lin
- Amgen Inc., Thousand Oaks and San Francisco, CA, USA
| | - M Maricic
- University of Arizona School of Medicine, Tucson, AZ, USA
| | - C D O'Malley
- Amgen Inc., Thousand Oaks and San Francisco, CA, USA
| | - K Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
24
|
Trijau S, de Lamotte G, Pradel V, Natali F, Allaria-Lapierre V, Coudert H, Pham T, Sciortino V, Lafforgue P. Osteoporosis prevention among chronic glucocorticoid users: results from a public health insurance database. RMD Open 2016; 2:e000249. [PMID: 27486526 PMCID: PMC4947732 DOI: 10.1136/rmdopen-2016-000249] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 01/29/2023] Open
Abstract
Introduction Long-term glucocorticoid therapy is the leading cause of secondary osteoporosis. The management of glucocorticoid-induced osteoporosis (GIOP) seems to be inadequate in many European countries. Objective To evaluate the rate of screening and treatment of GIOP. Design Information was collected from a national public health-insurance database in our geographic area of Provence-Alpes-Côte-d'Azur and in Corsica, from September 2009 through August 2011. Patients We identified participants aged 15 years and over starting glucocorticoid therapy (≥7.5 mg of prednisone equivalent per day during at least 90 days consecutive). This cohort was compared with an age-matched and sex-matched population that did not receive glucocorticoids. Main outcome measures Bone mass, prescription of bone antiresorptive medication and use of calcium and/or vitamin D treatment. Results We identified 32 812 patients who were prescribed glucocorticoid therapy, yielding 1% prevalence. Incidence of glucocorticoid therapy was 2.8/1000 inhabitants/year. Males represented 44%, the mean age was 58 years. The median prednisone-equivalent dose was 11 mg/day (IQR 9–18 mg/day). 8% underwent bone mass measurement. Calcium and/or vitamin D, and bisphosphonates were prescribed in 18% and 12%, respectively. Results were lower for the control population: 3% underwent bone mass measurement and 3% received bisphosphonate therapy. The rates of osteodensitometry and treatments were higher in women over 55 years of age than in men and women 55 years of age and younger, and also when glucocorticoid therapy was initiated by a rheumatologist versus other physician specialty. Conclusions The management of GIOP remains very inadequate, despite the availability of a statutory health insurance system. Targeted interventions are needed to improve the management of GIOP.
Collapse
Affiliation(s)
- Sophie Trijau
- Service de Rhumatologie , APHM, Hôpital Sainte-Marguerite , Marseille , France
| | - Gaëlle de Lamotte
- Service de Rhumatologie, APHM, Hôpital Sainte-Marguerite, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Vincent Pradel
- Service de Santé Publique et d'Information Médicale , APHM, Hôpital Sainte-Marguerite , Marseille , France
| | - François Natali
- Direction Régionale du Service Médical du Régime Général de l'Assurance Maladie Paca Corse , Marseille , France
| | - Véronique Allaria-Lapierre
- Direction Régionale du Service Médical du Régime Général de l'Assurance Maladie Paca Corse , Marseille , France
| | - Hervé Coudert
- Direction Régionale du Service Médical du Régime Général de l'Assurance Maladie Paca Corse , Marseille , France
| | - Thao Pham
- Service de Rhumatologie, APHM, Hôpital Sainte-Marguerite, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Vincent Sciortino
- Direction Régionale du Service Médical du Régime Général de l'Assurance Maladie Paca Corse , Marseille , France
| | - Pierre Lafforgue
- Service de Rhumatologie, APHM, Hôpital Sainte-Marguerite, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France
| |
Collapse
|
25
|
Tory HO, Solomon DH, Desai SP. Analysis of quality improvement efforts in preventing glucocorticoid-induced osteoporosis. Semin Arthritis Rheum 2016; 44:483-488. [PMID: 25845488 DOI: 10.1016/j.semarthrit.2014.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 09/05/2014] [Accepted: 09/19/2014] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To report and analyze quality improvement (QI) efforts that are aimed at increasing adherence to preventive guidelines for glucocorticoid-induced osteoporosis (GIOP). METHODS We performed a PubMed literature search for full-length articles in English between 1966 and 2013, describing approaches for improving the quality of GIOP care. We reviewed articles using a structured approach and abstracted information on the patient population, study design, QI intervention, and primary outcome measures. A descriptive analysis was then performed. RESULTS Literature search identified 661 articles; 38 were screened by abstract, 10 were identified for full review, and 7 were included. Two non-randomized, uncontrolled studies of system changes showed significant improvements in GIOP prevention: one increased concomitant prescriptions of glucocorticoids and calcium (37-49%, p < 0.0001) and vitamin D (38-53%, p < 0.0001) using a computerized order entry system; another used a dedicated clinical team to increase vitamin D levels from 19.5 to 29.4 (p = 0.001) and improve GIOP-related habits. Five articles described education-based interventions, including 3 randomized controlled trials (RCTs). Two non-significant RCTs focused on physicians, but one directed towards pharmacists and patients did increase calcium supplementation in the intervention vs. control arm (55.7% vs. 31.6%, p < 0.05). Two other non-randomized educational interventions did not show benefits. Comparison of articles was limited by the heterogeneity of the intervention methods and outcome measures used. CONCLUSION None of the interventions produced robust changes, with overall adherence to GIOP guidelines remaining low. System-based interventions appeared more effective than education-based interventions, but a diverse array of factors likely needs to be addressed, requiring more randomized controlled trials and greater standardization of outcome measures.
Collapse
Affiliation(s)
- Heather O Tory
- Rheumatology Program, Division of Immunology, Boston Children׳s Hospital, Boston, MA; Center for Clinical Excellence, Brigham and Women׳s Hospital, 1620 Tremont St, 2nd Floor, Boston, MA 02120.
| | - Daniel H Solomon
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women׳s Hospital, Boston, MA; Division of Pharmacoepidemiology, Brigham and Women׳s Hospital, Boston, MA
| | - Sonali P Desai
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women׳s Hospital, Boston, MA
| |
Collapse
|
26
|
Albaum JM, Lévesque LE, Gershon AS, Liu G, Cadarette SM. Glucocorticoid-induced osteoporosis management among seniors, by year, sex, and indication, 1996-2012. Osteoporos Int 2015; 26:2845-52. [PMID: 26138581 DOI: 10.1007/s00198-015-3200-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/05/2015] [Indexed: 01/30/2023]
Abstract
UNLABELLED We identified that glucocorticoid-induced osteoporosis management (bone mineral density testing or osteoporosis treatment) among seniors improved among men (2 to 23 %) and women (10 to 48 %) between 1996 and 2007, and then remained relatively stable through to 2012. Differences were also noted by indication (from a low of 21 % for respiratory conditions to a high of 41 % for rheumatic conditions). PURPOSE The aim of our study was to describe the proportion of chronic oral glucocorticoid (GC) users that receive osteoporosis management (bone mineral density test or osteoporosis treatment) by sex and over time. METHODS We identified community-dwelling older adults initiating chronic oral GC therapy in Ontario using pharmacy data from 1996 to 2012. Chronic GC use was defined as greater than or equal to two oral GC prescriptions dispensed and ≥450 mg prednisone equivalent over a 6-month period. Osteoporosis management within 6 months of starting chronic GC therapy was examined by sex, year, indication for therapy, and osteoporosis management history. Results were summarized using descriptive statistics. RESULTS We identified 72,099 men and 95,975 women starting chronic oral GC therapy (mean age = 74.9 years, SD = 6.5). Approximately two thirds of patients (65 %) received ≥900 mg within the 6-month chronic use window. GC-induced osteoporosis management increased from 2 to 23 % (men) and 10 to 48 % (women) between 1996 and 2007, and then remained relatively stable through to 2012. A higher proportion of patients with prior osteoporosis management were managed within 6 months (56 % men, 67 % women) of chronic GC use, compared to patients without prior management (12 % men, 23 % women). Patients with rheumatic disease were managed most commonly (41 %), and patients with respiratory conditions were managed least commonly (21 %). CONCLUSIONS GC-induced osteoporosis management improved significantly over time for both sexes yet remains low. Significant care gaps by sex and between clinical areas represent a missed opportunity for fracture prevention among patients requiring chronic GC therapy.
Collapse
Affiliation(s)
- J M Albaum
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada
| | - L E Lévesque
- Queen's University, Kingston, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - A S Gershon
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - G Liu
- Queen's University, Kingston, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - S M Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada.
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
| |
Collapse
|
27
|
Abstract
PURPOSE OF REVIEW This manuscript will provide a review of recent publications, examining the correlation of systemic lupus erythematosus (SLE) with changes in bone health and associated osteoporosis, highlighting prevalence, etiology, diagnosis, and treatment. RECENT FINDINGS Studies suggest that bone loss and fractures are associated with SLE, related not only to the disease itself, but also with low vitamin D and treatment side-effects. Understanding the mechanisms of glucocorticoids on bone and the immunologic relationship of vitamin D, as well as recognizing the role of chronic inflammation on bone, allows for better understanding of skeletal side-effects. Further awareness of the association of poor bone health has led to an increased need for prevention and treatment. New imaging and treatment are emerging, although not recommended currently. SUMMARY Loss of bone density culminating in osteoporosis and fracture is a frequent comorbidity in SLE patients at any age and is multifactorial in etiology. Awareness and diagnosis is crucial because of its prevalence and morbidity. Prevention is safe and effective in this high-risk population where diagnostic measures and interventions are underutilized and guidelines are lacking.
Collapse
Affiliation(s)
- Cuoghi Edens
- aDepartment of Pediatrics, Division of Pediatric Infectious Diseases and Rheumatology, Rainbow Babies and Children's Hospital bDepartment of Internal Medicine, Division of Rheumatology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | | |
Collapse
|
28
|
Health care utilization before and after intensive care unit admission in multiple sclerosis. Mult Scler Relat Disord 2015. [DOI: 10.1016/j.msard.2015.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
29
|
Abstract
BACKGROUND To determine predictors of intensive care unit (ICU) admission and to assess health care utilization (HCU) post-ICU admission among persons with inflammatory bowel disease (IBD). METHODS We matched a population-based database of Manitobans with IBD to a general population cohort on age, sex, and region of residence and linked these cohorts to a population-based ICU database. We compared the incidence rates of ICU admission among prevalent IBD cases according to HCU in the year before admission using generalized linear models adjusting for age, sex, socioeconomic status, region, and comorbidity. Among incident cases of IBD who survived their first ICU admission, we compared HCU with matched controls who survived ICU admission. RESULTS Risk factors for ICU admission from the year before admission included cumulative corticosteroid use (incidence rate ratio, 1.006 per 100 mg of prednisone; 95% confidence interval, 1.004-1.008) and IBD-related surgery (incidence rate ratio, 2.79; 95% confidence interval, 1.99-3.92). Use of immunomodulatory therapies within 1 year, or surgery for IBD beyond 1 year prior, were not associated with ICU admission. In those who used corticosteroids and immunomodulatory medications in the year before ICU admission, the use of immunomodulatory medications conferred a 30% risk reduction in ICU admission (incidence rate ratio, 0.70; 95% confidence interval, 0.50-0.97). Persons with IBD who survived ICU admission had higher HCU in the year following ICU discharge than controls. CONCLUSIONS Corticosteroid use and surgery within the year are associated with ICU admission in IBD while immunomodulatory therapy is not. Surviving ICU admission is associated with high HCU in the year post-ICU discharge.
Collapse
|
30
|
Kenanidis E, Potoupnis ME, Kakoulidis P, Leonidou A, Sakellariou GT, Sayegh FE, Tsiridis E. Management of glucocorticoid-induced osteoporosis: clinical data in relation to disease demographics, bone mineral density and fracture risk. Expert Opin Drug Saf 2015; 14:1035-53. [PMID: 25952267 DOI: 10.1517/14740338.2015.1040387] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Glucocorticoid-induced osteoporosis (GIOP) is the most common type of secondary osteoporosis. Patient selection and the treatment choice remain to be controversial. None of the proposed management guidelines are widely accepted. We evaluate the available clinical data, the efficacy of current medication and we propose an overall algorithm for managing GIOP. AREAS COVERED This article provides a critical review of in vivo and clinical evidence regarding GIOP and developing evidence-based algorithm of treatment. Data base used includes MEDLINE® (1950 to May 2014). EXPERT OPINION Patient-specific treatment is the gold standard of care. Glucocorticoid (GC)-treated patients must comply with a healthy lifestyle and receive 1000 mg of calcium and at least 800 mg of Vitamin D daily. Bisphosphonate (BP) therapy is the current standard of care for prevention and treatment of GIOP. Most of bisphosphonates demonstrated benefit in lumbar bone mineral density (BMD) and some in hip BMD. Alendronate, risedronate and zoledronate showed vertebral anti-fracture efficacy in postmenopausal women and men. Scarce data however when compared head to head with BP efficacy. In post-menopausal women, early antiresorptive BP treatment appears to be efficient and safe. In premenopausal women and patients at high risk of fracture receiving long-term GC therapy however, teriparitide may be advised alternatively.
Collapse
Affiliation(s)
- Eustathios Kenanidis
- Aristotle University Medical School, Academic Orthopaedic Unit , Thessaloniki , Greece
| | | | | | | | | | | | | |
Collapse
|
31
|
Overman RA, Toliver JC, Yeh JY, Gourlay ML, Deal CL. United States adults meeting 2010 American College of Rheumatology criteria for treatment and prevention of glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken) 2014; 66:1644-52. [PMID: 24719294 DOI: 10.1002/acr.22346] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 04/01/2014] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The American College of Rheumatology (ACR) updated its guidelines on the prevention and treatment of glucocorticoid-induced osteoporosis (GIO) in 2010. An unknown proportion of US adults at risk of fracture due to glucocorticoid use would be recommended antiosteoporosis pharmaceutical (AOP) therapies based on the ACR guidelines. METHODS Using the 2005-2010 National Health and Nutrition Examination Survey (NHANES) data for postmenopausal women (PMW), and men age ≥50 years reporting current glucocorticoid use, we categorized individuals according to ACR criteria for low, medium, and high fracture risk (<10%, ≥10%, and ≥20%, respectively) and provided percentages of treatment recommendations for chronic (≥90 days) medium and all high-risk patients. RESULTS Glucocorticoids were used by 1.66% of PMW and 1.65% of men age ≥50 years. Of these patients, 0.80% of PMW and 0.45% of men age ≥50 years were at high risk of fracture. A majority of PMW (81.2%) and men age ≥50 years (75.8%) were chronic glucocorticoid users. In patients for whom treatment recommendations could be made, 64.9% of PMW and 51.9% of men age ≥50 years would be recommended therapy, but only 28.4% of PMW and 9.7% of men age ≥50 years reported AOP use. CONCLUSION Based on the NHANES (2005-2010) data, we estimate glucocorticoid use in >1.5 million US PMW and men age ≥50 years. Treatment would be recommended in at least 50% of this population based on the 2010 ACR guidelines. Self-reported AOP use was documented in <30%, suggesting a treatment gap in the management of GIO in the US before the guideline release.
Collapse
Affiliation(s)
- Robert A Overman
- University of North Carolina, Chapel Hill, and Cleveland Clinic Foundation, Cleveland, Ohio
| | | | | | | | | |
Collapse
|
32
|
Abstract
Among the adverse events of glucocorticoid treatment are bone loss and fractures. Despite available, effective preventive measures, many patients receiving or initiating glucocorticoid therapy are not appropriately evaluated and treated for bone health and fracture risk. Populations with, or at risk of, glucocorticoid-induced osteoporosis (GIOP) to target for these measures are defined on the basis of dose and duration of glucocorticoid therapy and bone mineral density. That patients with GIOP should be treated as early as possible is generally agreed upon; however, diversity remains in intervention thresholds and management guidelines. The FRAX(®) algorithm provides a 10-year probability of fracture that can be adjusted according to glucocorticoid dose. There is no evidence that GIOP and postmenopausal osteoporosis respond differently to treatments. Available anti-osteoporotic therapies such as anti-resorptives including bisphosphonates and the bone anabolic agent teriparatide are effective for the management of GIOP. Prevention with calcium and vitamin D supplementation is less effective than specific anti-osteoporotic treatment. Anti-osteoporotic treatment should be stopped at the time of glucocorticoid cessation, unless the patient remains at increased risk of fracture.
Collapse
|
33
|
Kamphuis LS, Bonte-Mineur F, van Laar JA, van Hagen PM, van Daele PL. Calcium and vitamin D in sarcoidosis: is supplementation safe? J Bone Miner Res 2014; 29:2498-503. [PMID: 24753153 DOI: 10.1002/jbmr.2262] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 03/25/2014] [Accepted: 03/30/2014] [Indexed: 11/06/2022]
Abstract
Granulomas in sarcoidosis express high levels of 1α-hydroxylase, an enzyme that catalyzes the hydroxylation of 25-OH vitamin D to its active form, 1,25(OH)2 vitamin D. Overproduction of 1α-hydroxylase is held responsible for the development of hypercalcemia in sarcoidosis patients. Corticosteroids are used as first-line treatment in organ-threatening sarcoidosis. In this light, osteoporosis prevention with calcium and vitamin D (CAD) supplementation is often warranted. However, sarcoidosis patients are at risk for hypercalcemia, and CAD supplementation affects the calcium metabolism. We studied calcium and vitamin D disorders in a large cohort of sarcoidosis patients and investigated if CAD supplementation is safe. Retrospectively, data of 301 sarcoidosis patients from July 1986 to June 2009 were analyzed for serum calcium, 25-hydroxy vitamin D (25-(OH)D), 1,25-dihydroxy vitamin D (1,25(OH)2 D), and use of CAD supplementation. Disease activity of sarcoidosis was compared with serum levels of vitamin D. Hypercalcemia occurred in 8%. A significant negative correlation was found between 25-(OH)D and disease activity of sarcoidosis measured by somatostatin receptor scintigraphy. In our study, 5 of the 104 CAD-supplemented patients developed hypercalcemia, but CAD supplementation was not the cause of hypercalcemia. Patients without CAD supplementation were at higher risk for developing hypercalcemia. During CAD supplementation, no hypercalcemia developed as a result of supplementation. Hypovitaminosis D seems to be related with more disease activity of sarcoidosis and, therefore, could be a potential risk factor for disease activity of sarcoidosis. Thus, vitamin D-deficient sarcoidosis patients should be supplemented.
Collapse
Affiliation(s)
- Lieke S Kamphuis
- Department of Immunology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands; Department of Internal Medicine, Section of Clinical Immunology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | | | | | | | | |
Collapse
|
34
|
Modi A, Sajjan S, Gandhi S. Challenges in implementing and maintaining osteoporosis therapy. Int J Womens Health 2014; 6:759-69. [PMID: 25152632 PMCID: PMC4140231 DOI: 10.2147/ijwh.s53489] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In the United States, an estimated 19% of older men and 30% of older women are at elevated risk of osteoporotic fracture and considered to be eligible for treatment. The burden of osteoporosis is similar in Europe and is projected to rise worldwide, with aging populations and increasing fracture rates accompanying urbanization. Notwithstanding its high prevalence, osteoporosis is often underdiagnosed and undertreated. Moreover, even when the diagnosis is made and the decision is taken to treat, there are remaining challenges in implementing therapy for osteoporosis. Several patient populations are particularly challenging for clinicians to treat and require further study with regard to osteoporosis therapy. These include the very elderly, who face challenges relating to adherence; men, in whom osteoporosis remains under-recognized; patients with glucocorticoid-induced osteoporosis or renal impairment, who are at increased risk of fracture; patients with preexisting gastrointestinal problems who cannot tolerate existing orally administered osteoporosis therapies; and high-risk patients who show inadequate response to therapy. Moreover, poor adherence and poor persistence with osteoporosis medications are common and result in an increased risk of fracture, higher medical costs, and increased hospitalizations. Once the decision to institute therapy is made, patient education about osteoporosis and fracture risk should be provided. This is particularly important for men, who may not be aware that osteoporosis can be a concern. Secondary prevention programs, including fracture liaison services and bone therapy groups, can help to improve adherence to therapy. Further study is needed to guide the treatment of men, the very elderly, patients with glucocorticoid-induced osteoporosis and renal impairment, high-risk patients not well-controlled despite therapy, and patients with preexisting gastrointestinal conditions. Moreover, therapies are needed that are viewed as effective and safe by both physicians and patients, and as convenient to take by patients.
Collapse
Affiliation(s)
- Ankita Modi
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Whitehouse Station, NJ, USA
| | - Shiva Sajjan
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Whitehouse Station, NJ, USA
| | - Sampada Gandhi
- School of Public Health, Rutgers University, Piscataway, NJ, USA
| |
Collapse
|
35
|
Kuchuk NO, Hoes JN, Bijlsma JWJ, Jacobs JWG. Glucocorticoid-induced osteoporosis: an overview. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/ijr.14.24] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
36
|
Klop C, de Vries F, Vinks T, Kooij MJ, van Staa TP, Bijlsma JWJ, Egberts ACG, Bouvy ML. Increase in prophylaxis of glucocorticoid-induced osteoporosis by pharmacist feedback: a randomised controlled trial. Osteoporos Int 2014; 25:385-92. [PMID: 24221450 PMCID: PMC3889504 DOI: 10.1007/s00198-013-2562-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 10/16/2013] [Indexed: 01/30/2023]
Abstract
UNLABELLED The aim of this study was to determine whether feedback by pharmacists to prescribers of patients eligible for glucocorticoid-induced osteoporosis prophylaxis would stimulate the prescribing of osteoporosis prophylaxis. The intervention did not significantly increase the prescribing of bisphosphonates in the total study population, but a significant increase was seen in men and in the elderly. However, the proportion of bisphosphonate-treated patients remained low. INTRODUCTION The aim of this study was to determine whether feedback by pharmacists to prescribers of patients eligible for glucocorticoid-induced osteoporosis prophylaxis (GIOP) would stimulate the implementation of the Dutch GIOP guideline. METHODS This randomised controlled trial included 695 patients who were dispensed ≥675 mg prednisone equivalents without a concomitant bisphosphonate prescription within 6 months before baseline. Pharmacists were asked to contact the physicians of GIOP-eligible patients in the intervention group to suggest osteoporosis prophylaxis. The primary endpoint was a bisphosphonate prescription. Secondary endpoints were a prescription of calcium supplements, vitamin D or any prophylactic osteoporosis drug (bisphosphonate, calcium supplements, vitamin D). RESULTS The group assigned to the intervention was slightly younger than the control group (68.7 ± 15.4 vs. 65.9 ± 16.9 years, p = 0.02) and used hydrocortisone more often (7.0% vs. 3.1%, p = 0.02). Within 6 months, the intervention did not significantly increase the prescribing of bisphosphonates (11.4% after intervention vs. 8.0% for controls; hazard ratio [HR] 1.47, 95% confidence interval [CI] 0.91-2.39). However, subgroup analyses showed a significant increase for the primary endpoint in men (12.8% vs. 5.1%, HR 2.53, 95% CI 1.11-5.74) and patients ≥70 years (13.4% vs. 4.9%, HR 2.88, 95% CI 1.33-6.23). The prescribing of calcium and vitamin D was not significantly altered. CONCLUSION This study showed that active identification of patients eligible for GIOP by pharmacists did not significantly increase the prescribing of bisphosphonates in the total study population, but there was an increase in men and the elderly. However, the proportion of GIOP-treated patients remained low.
Collapse
Affiliation(s)
- C. Klop
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - F. de Vries
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK
- Department of Clinical Pharmacy & Toxicology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Maastricht University/CAPHRI, Maastricht, The Netherlands
| | - T. Vinks
- Pharmacy DeLeij, Tilburg, The Netherlands
| | - M. J. Kooij
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - T. P. van Staa
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK
| | - J. W. J. Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Centre, Utrecht, The Netherlands
| | - A. C. G. Egberts
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
- Hospital Pharmacy, University Medical Centre, Utrecht, The Netherlands
| | - M. L. Bouvy
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
- SIR Institute for Pharmacy Practice and Policy, Leiden, The Netherlands
| |
Collapse
|
37
|
Abstract
Rheumatologic diseases are associated with a proinflammatory state, which is thought to lead to many of the bone changes seen in treatment-naive patients. However, glucocorticoids remain a common treatment option for rheumatologic diseases and are known to have a negative impact on bone through direct effects on bone cells and indirect effects on calcium absorption. Despite the anti-inflammatory effect of glucocorticoids, fracture risk rises within the first 3 months of treatment. As such, osteoporosis prevention and treatment needs to be considered in all patients started on chronic glucocorticoids (≥3 months of treatment). For very low risk patients, conservative management with non-pharmacologic strategies may be appropriate. For the moderate to high fracture risk patients treated with glucocorticoids, pharmacologic treatment with 1 of the 4 approved medications should be considered. The challenge of educating physicians and patients of the risks of glucocorticoid induced osteoporosis remain.
Collapse
Affiliation(s)
- Amy H Warriner
- Division of Endocrinology, Metabolism and Diabetes, University of Alabama at Birmingham, 702 Faculty Office Tower, 510 20th Street South, Birmingham, AL, 35233, USA,
| | | |
Collapse
|
38
|
Li GW, Xu Z, Chen QW, Chang SX, Tian YN, Fan JZ. The temporal characterization of marrow lipids and adipocytes in a rabbit model of glucocorticoid-induced osteoporosis. Skeletal Radiol 2013; 42:1235-44. [PMID: 23754734 DOI: 10.1007/s00256-013-1659-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 05/10/2013] [Accepted: 05/22/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To characterize the temporal changes in marrow lipids content and adipocytes in the development of glucocorticoid-induced osteoporosis (GIOP) in rabbits using MR spectroscopy. SUBJECTS AND METHODS Twenty 20-week-old female rabbits were randomized to a control group and a GIOP group equally. Marrow lipids fraction and bone mineral density at the left proximal femur and L3-L4 vertebrae were measured by MR spectroscopy and dual-energy X-ray absorptiometry at week 0, 4, 8, and 12. Marrow adipocytes were quantitatively evaluated by histopathology. RESULTS Marrow adiposity in the GIOP group showed a significant increase over time, with a variation of marrow lipids fraction (+35.9 %) at week 4 from baseline and it was maintained until week 12 (+75.2 %, p < 0.001 for all). The GIOP group demonstrated continuous deterioration of bone with significant difference between the two groups at week 8, followed by increased marrow fat with significant difference at week 4 (p < 0.05 for all). In comparison with the controls, marrow adipocyte density in the GIOP group increased by 57.1 % at week 8 and 35.4 % at week 12, respectively. A reduction (-13.3 %) in adipocyte mean diameter at week 8 (but an increase (+22.7 %) at week 12) were observed in the GIOP group compared with the control group (p < 0.05 for all). There was significant difference between two periods (p = 0.023) in adipocyte mean diameter in the GIOP group. The percentage area of marrow adipocytes in the GIOP group was 62.8 ± 8.7 % at week 8 and 79.2 ± 7.7 % at week 12, both of which were significantly higher than those of the controls (p < 0.05 for all). CONCLUSIONS Marrow adipogenesis is synchronized with bone loss in the development of GIOP, which was characterized by a significant increase in the number of small-sized marrow adipocytes in the relatively early stage and concomitant volume increase later on. MR spectroscopy appears to be the most powerful tool for detecting the sequential changes in marrow lipid content.
Collapse
Affiliation(s)
- Guan-Wu Li
- Department of Radiology, Yueyang Hospital of Integrated Traditional Chinese & Western Medicine, Shanghai University of Traditional Chinese Medicine, No.110, Gan-he Road, Hong-kou District, Shanghai 200437, China
| | | | | | | | | | | |
Collapse
|
39
|
Majumdar SR, Morin SN, Lix LM, Leslie WD. Influence of recency and duration of glucocorticoid use on bone mineral density and risk of fractures: population-based cohort study. Osteoporos Int 2013; 24:2493-8. [PMID: 23572142 DOI: 10.1007/s00198-013-2352-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 02/20/2013] [Indexed: 10/27/2022]
Abstract
UNLABELLED Although systemic glucocorticoids are commonly used, it is difficult to obtain accurate exposure history. In 50,000 patients, we confirmed that glucocorticoids were associated with reductions in bone mineral density (BMD) and increases in fracture and documented that recent and prolonged durations of exposure were particularly associated with adverse events-dose information did not improve risk prediction. INTRODUCTION Systemic glucocorticoid use, defined as ever having taken supra-physiologic doses for 90-days or more, is a risk factor for low BMD and fractures. This definition does not distinguish recent (vs remote) exposure. METHODS Within a population-based clinical BMD registry in Manitoba, Canada, we identified all adults over age 40 years tested between 1998 and 2007 and then undertook a cohort study. We identified all oral glucocorticoid dispensations from 1995 to 2009 and stratified exposure by timing ("recent" if within 12 months vs "remote") and duration (short [<90 days] vs prolonged [≥90 days]). Osteoporosis-related risk factors and treatments and major fractures were obtained using administrative health data. RESULTS A total of 12,818 of 52,070 (25%) subjects had used glucocorticoids prior to BMD testing; the most common exposure was remote short (n = 6453) vs recent prolonged (n = 2896) vs recent short (n = 2644) vs remote prolonged (n = 825). Compared to 39,252 never-users, only recent prolonged glucocorticoid use was significantly associated with femoral neck T-score (ANCOVA-adjusted difference -0.13, 95% CI -0.16 to -0.10, p < 0.001). There were 2,842 major (566 hip) fractures over median 5-year follow-up. Compared with never-users, only recent prolonged glucocorticoid use was significantly associated with BMD-independent increases in risk of incident major fracture (5.4 vs 7.7%, adjusted HR 1.25, 95% CI 1.07-1.45, p = 0.004) and hip fracture (1.1 vs 1.8%, adjusted HR 1.61, 95% CI 1.18-2.20, p = 0.003). CONCLUSIONS Recent and prolonged glucocorticoid use (but neither remote nor recent short courses) was independently associated with reduced BMD and increased risk of fractures. These findings should permit clinicians to identify a high-risk group of patients that might benefit from osteoporosis prevention.
Collapse
Affiliation(s)
- S R Majumdar
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.
| | | | | | | |
Collapse
|
40
|
Laurent M, Gielen E, Claessens F, Boonen S, Vanderschueren D. Osteoporosis in older men: recent advances in pathophysiology and treatment. Best Pract Res Clin Endocrinol Metab 2013; 27:527-39. [PMID: 24054929 DOI: 10.1016/j.beem.2013.04.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Osteoporosis remains underrecognized and undertreated but more so in men, adding considerably to fracture burden and costs. Fracture-related morbidity and mortality is higher in men, partly due to greater frailty. Improved peak bone mass, geometry and turn-over contribute to lower fracture incidence in men. Bioavailable androgens and oestrogens regulate these aspects of musculoskeletal sexual dimorphism, yet the direct cellular and molecular targets of sex steroids in bone remain incompletely understood. Screening with clinical risk factors and dual energy X-ray absorptiometry are advised in men from age 70 (or 50 with additional risk factors). We now have compelling evidence that osteoporosis drugs are equally effective in men and women, not only to increase bone density but also to prevent osteoporotic fractures. The use of testosterone or selective androgen receptor modulators for osteoporosis, sarcopenia, frailty and falls in men with late-onset hypogonadism requires further investigation.
Collapse
Affiliation(s)
- Michaël Laurent
- Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium; Gerontology and Geriatrics, Department of Clinical and Experimental Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Laboratory of Molecular Endocrinology, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | | | | | | | | |
Collapse
|
41
|
Majumdar SR, Lix LM, Morin SN, Yogendran M, Metge CJ, Leslie WD. The disconnect between better quality of glucocorticoid-induced osteoporosis preventive care and better outcomes: a population-based cohort study. J Rheumatol 2013; 40:1736-41. [PMID: 23818715 DOI: 10.3899/jrheum.130041] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The quality of glucocorticoid-induced osteoporosis (GIOP) care [defined by bone mineral density (BMD) testing or osteoporosis treatment] is suboptimal and has been targeted for improvement. The assumption that improvements in GIOP preventive care will lead to better outcomes has not been tested. METHODS We used linked healthcare databases to conduct a population-based study of all adults 20 years of age or older in Manitoba, Canada, who initiated longterm (> 90 days) systemic glucocorticoids (GC) between 1998 and 2008. High-quality GIOP care was defined by BMD testing or prescription osteoporosis treatment within 6 months. Outcomes were adjusted odds of major fractures within 1 year and 3 years. RESULTS We studied 15,285 subjects who had just begun to take GC; 5804 (38%) were 70 years of age or older, 9185 (58%) were women, and 4755 (30%) received 10 mg or more prednisone equivalents daily. Overall, 3898 (25%) subjects received a BMD test or osteoporosis treatment within 6 months. Within 1 year of starting GC, there had been 206 major fractures (1%) and within 3 years, 553 major fractures (4%). High-quality GIOP preventive care was not associated with a reduced risk of major fractures within 1 year (adjusted OR 1.6, 95% CI 1.2-2.1) or within 3 years (adjusted OR 1.3, 95% CI 1.1-1.6). CONCLUSION Three-quarters of those initiating GC received suboptimal osteoporosis care. Conventional administrative database analyses could not demonstrate that better GIOP preventive care was associated with reductions in medically attended fractures. Clinically rich databases and different analytic techniques are needed to better evaluate the effectiveness of GIOP preventive care.
Collapse
Affiliation(s)
- Sumit R Majumdar
- From the Department of Medicine, University of Alberta, Edmonton, Alberta; the Departments of Community Health Sciences and Medicine and Radiology, University of Manitoba, Winnipeg, Manitoba; and the Department of Medicine, McGill University, Montreal, Quebec, Canada
| | | | | | | | | | | |
Collapse
|
42
|
Li GW, Chang SX, Fan JZ, Tian YN, Xu Z, He YM. Marrow adiposity recovery after early zoledronic acid treatment of glucocorticoid-induced bone loss in rabbits assessed by magnetic resonance spectroscopy. Bone 2013; 52:668-75. [PMID: 23142803 DOI: 10.1016/j.bone.2012.11.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 10/30/2012] [Accepted: 11/01/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although there is an inverse relationship between bone mass and marrow adiposity, the reversal function of zoledronic acid (ZOL) on increased marrow fat has not been studied. The aim of our study is to use the 3T magnetic resonance spectroscopy (MRS) to characterize the dynamical change process of the marrow fat responding to early ZOL treatment in the rabbit model with glucocorticoid-induced bone loss. METHODS Fifteen 20-week-old female New Zealand White rabbits were randomized to control group, methylprednisolone (MPS) group, and MPS+ZOL group equally. Bone mineral density (BMD) and marrow fat fraction (FF) at L3-L4 vertebrae and left proximal femur were measured by Dual-energy X-ray absorptiometry and MRS at week 0, 4, 8, and 12. The animals were euthanized at the end of our experiment and their left femurs were dissected out for the histopathological examination. RESULTS The MPS group demonstrated a remarkable increase in FF but a reduction in BMD compared with the controls at week 4 and 8, respectively (P<0.05 for all). Early treatment of ZOL can inhibit bone degeneration, although the bone mass would not recover to its original level. FF in MPS group exhibited a dramatic increase over time, with an increased FF variation (+31.6%, P=0.009) at week 4 from baseline and it was maintained until week 12 (+75.2%, P<0.001). In MPS+ZOL group, the FF returned to baseline value after the ZOL treatment. Comparing with the controls, larger marrow adipocyte density, the mean of the adipocyte diameter, and the percentage area of the adipocyte were observed in the MPS group (P<0.05 for all), whereas there were no significant differences in quantitative parameters of marrow adipocytes between the ZOL-treated group and the normal rabbits. CONCLUSION An increase of the marrow adiposity is synchronized with the deterioration of the MPS-induced bone mass. A single dose of early ZOL can reverse the marrow adiposity to its original level completely.
Collapse
Affiliation(s)
- Guan-Wu Li
- Department of Radiology, Yueyang Hospital affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China.
| | | | | | | | | | | |
Collapse
|
43
|
Ko SH, Lee KY, Kim KH, Kim YM, Lee KS, Yeom SJ, Kang MI. A Case with Multiple Punched-out Lesions in the Skull and Generalized Fractures Associated with Steroid-induced Osteoporosis. J Bone Metab 2012; 19:133-8. [PMID: 24524044 PMCID: PMC3780929 DOI: 10.11005/jbm.2012.19.2.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 05/26/2012] [Accepted: 05/31/2012] [Indexed: 12/03/2022] Open
Abstract
Steroid-induced osteoporosis is the most common cause of secondary osteoporosis and accounts for one-fifth of all osteoporosis cases. The fracture incidence under steroid may be as high as 50%. However, many patients do not undergo appropriate risk assessment and treatment before and after steroid exposure. We described a 56-year-old male patient with multiple punched-out lesions in skull unusually as well as vertebral, fibular, rib and humeral fractures during steroid use without proper management.
Collapse
Affiliation(s)
- Sun Hee Ko
- Department of Internal Medicine, Division of Endocrinology and Metabolism, The Catholic University of Korea, Seoul, Korea
| | - Kwan Yong Lee
- Department of Internal Medicine, Division of Endocrinology and Metabolism, The Catholic University of Korea, Seoul, Korea
| | - Kyung Hee Kim
- Department of Internal Medicine, Division of Endocrinology and Metabolism, The Catholic University of Korea, Seoul, Korea
| | - Young Min Kim
- Department of Internal Medicine, Division of Endocrinology and Metabolism, The Catholic University of Korea, Seoul, Korea
| | - Kyeong Soo Lee
- Department of Internal Medicine, Division of Endocrinology and Metabolism, The Catholic University of Korea, Seoul, Korea
| | - Soo Jeong Yeom
- Department of Internal Medicine, Division of Endocrinology and Metabolism, The Catholic University of Korea, Seoul, Korea
| | - Moo Il Kang
- Department of Internal Medicine, Division of Endocrinology and Metabolism, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|